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Patient Registration Form.

Remington Family Dentistry

510 Wellness Way,Remington, IN, 47977(219) 261-2217

Patient Details( * mandatory to fill )

First Name*

Last Name*

Middle Name

City*

State*

Zip*

Date Of Birth*

Address*

Gender*

Marital Status*

Social Security Number*

Driving License Number

Contact Information( * mandatory to fill )

Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Extension Number

Responsible Party's Information( * mandatory to fill )

Address*

City*

State*

Zip*

Home Phone Number

Cell Phone Number

Work Phone Number

Work Extension Number

Social Security Number

Driving License Number

Emergency Contact Information( * mandatory to fill )

Name

Phone Number

Primary Insurance Details( * mandatory to fill )

Relation To Patient

Name Of Insured

Insured SSN

EmployerName

Insured Person's Address

DOB of Insured

Group Number

Rem. Benefits

Rem. Deduct

Insurance Company

Insurance Company Address

Insurance Company City

Insurance Company State

Insurance Company ZipCode

Medical History( * mandatory to fill )

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could h

Are you under a physician's care now?

yes

no

If Yes,

Have you ever been hospitalized or had a major operation?

yes

no

If Yes,

Have you ever had a serious head or neck injury?

yes

no

If Yes,

Are you taking any medications, pills or drugs?

yes

no

If Yes,

Do you take, or have you taken,phen-fen or Redux

yes

no

If Yes,

Have you ever taken Fosamax, Boniva,actonel or any other medications containing bisphosphonates?

yes

no

If Yes,

Are you on a special diet?

yes

no

Do you use tobacco?

yes

no

Do you use controlled substances?

yes

no

If Yes,

Women, are you?

Pregnant/trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin

Pencillin

Codeine

Acrylic

metal

Latex

sulfa drugs

Local anesthetics

Other

If Yes,

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Yes

No

Alzheimer's Disease

Yes

No

Anaphylaxis

Yes

No

Anemia

Yes

No

Angina

Yes

No

Arthritis/Gout

Yes

No

Artificial Heart Valves

Yes

No

Artificial Joints

Yes

No

Asthma

Yes

No

Blood Disease

Yes

No

Blood Transfusion

Yes

No

Breathing Problems

Yes

No

Bruise Easily

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Cold sores / Fever blisters

Yes

No

Congenital heart disorder

Yes

No

Convulsion

Yes

No

Cortisone medicine

Yes

No

Diabetes

Yes

No

Difficulty Breathing

Yes

No

Drug Addiction

Yes

No

Easily Winded

Yes

No

Emphysema

Yes

No

Epilepsy or Seizures

Yes

No

Excessive Bleeding

Yes

No

Excessive Thirst

Yes

No

Fainting spells / Dizziness

Yes

No

Frequent Cough

Yes

No

Frequent Diarrhea

Yes

No

Frequent Headaches

Yes

No

Genital Herpes

Yes

No

Glaucoma

Yes

No

Hay Fever

Yes

No

Heart Attack / Failure

Yes

No

Heart Murmer

Yes

No

Heart Pacemaker

Yes

No

Heart Trouble / Disease

Yes

No

Hemophilia

Yes

No

Hepatitis A

Yes

No

Hepatitis B or C

Yes

No

Herpes

Yes

No

High Blood Pressure

Yes

No

High Cholesterol

Yes

No

Hives or Rash

Yes

No

Hypoglycemia

Yes

No

Irregular Heartbeat

Yes

No

Kidney Problem

Yes

No

Leukemia

Yes

No

Liver Disease

Yes

No

Low Blood Pressure

Yes

No

Lung diseases

Yes

No

Mitral Value prolapse

Yes

No

Osteoporosis

Yes

No

Pain in Jaw Joints

Yes

No

Parathyroid Disease

Yes

No

Psychiatric Care

Yes

No

Radiation Treatments

Yes

No

Recent Weight Loss

Yes

No

Renal Dialysis

Yes

No

Rheumatic Fever

Yes

No

Rheumatism

Yes

No

Scarlet Fever

Yes

No

Shingles

Yes

No

Sickle Cell Disease

Yes

No

Sinus Trouble

Yes

No

Spina Bifida

Yes

No

Stomach/Intestinal Disease

Yes

No

Stroke

Yes

No

Swelling of Limbs

Yes

No

Thyroid Disease

Yes

No

Tonsillitis

Yes

No

Tuberculosis

Yes

No

Tumors or Growths

Yes

No

Ulcers

Yes

No

Venereal Disease

Yes

No

Yellow Jaundice

Yes

No

SIGNATURE *

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES( * mandatory to fill )

I have had full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permission.